MORBIDITY OF ENDOTRACHEAL INTUBATION AND TRACHEOSTOMY
Nasotracheal tubes may be more easily inserted, less easily dislodged, and sometimes better tolerated than orotracheal tubes. However, they can cause nasal necrosis and maxillary sinusitis. “Blind insertion” may result in vocal cord trauma, which can be minimized by visualization, as with oral intubation. Nasotracheal tubes have small lumina, making suctioning and weaning from mechanical ventilation difﬁcult. Orotracheal tubes are larger and more readily permit suctioning or bronchoscopy than nasotracheal tubes. However, they are less comfortable, more easily dislodged, and can be kinked or damaged by the patient’s teeth.
Complications of intubation are caused by the pharmacologic and physiologic effects of medications and manipulation of the upper airway as well as mechanical injury from the laryngoscope, endotracheal tube, or stylet. Mechanical complications may include nasal, dental, or oropharyngeal trauma. Laryngospasm, laryngeal edema, aspiration of gastric contents, and intubation of the esophagus or right main bronchus may also occur. Additionally, tracheal injury, including rupture from the stylet may also be seen and is typically found at the junction of the posterior membrane with the cartilaginous trachea.
During mechanical ventilation, several problems may occur. Obstruction of the tube can be secondary to kinking, mucus plugging, blood clots, or slippage or overinﬂation of the cuff over the end of the tube. Cuff leaks caused by rupture may also occur, resulting in decreased minute ventilation and aspiration of secretions.
A serious complication of both tracheostomy and endotracheal intubation is the development of a tracheoesophageal ﬁstula. A ﬁstula should be suspected when air leaks, aspiration of saliva or secretions, or any signs of respiratory distress are noted. The diagnosis may be conﬁrmed by bronchoscopy. The presence of a nasogastric tube may predispose to ﬁstula formation caused by pressure necrosis between the trachea and esophagus.
Although occurring in fewer than 1% of patients with tracheostomy tubes, tracheoinnominate ﬁstula may also occur; when untreated, it is associated with a mortality of 100%. The innominate artery typically traverses the trachea at the level of the ninth tracheal ring, although it may also do so between the sixth and thirteenth rings. Patients often present with peristomal bleeding or hemoptysis, which can be mild, moderate, or severe. If suspected, an emergent surgical consultation is required. Acute and chronic problems may occur after extubation. An immediate complication is laryngospasm, which may require reintubation or tracheostomy. Minor problems such as sore throat and temporary hoarseness are frequent. Chronic problems include vocal cord incompetence, polyps, or ulcerations and development of a subglottic or tracheal stenosis or tracheomalacia. These can be diagnosed by indirect laryngoscopy or bronchoscopy. Common sites for stenosis and malacia include the area occupied by the cuff or tip of the endotracheal or tracheostomy tube as well as the superior tracheostomy stoma.
Bleeding and subcutaneous emphysema are more or less unique to tracheostomy. Bleeding at the incision site may be obvious or may occur internally with aspiration of blood. If the tracheostomy tube becomes dislodged, reinsertion is sometimes difﬁcult, especially with a fresh tracheostomy. If a dislodged tracheostomy tube cannot be quickly and easily reinserted, endotracheal intubation or ventilation by mask may be required until an experienced surgeon is available. If a tracheostomy tube is inadvertently removed before the formation of a stoma (7-10 days after placement), replacement should not be attempted unless the airway is secured initially with an endotracheal tube.